Abstract

As the U.S. healthcare system continues to shift toward value-based care, hospitals are increasingly called upon to address social determinants of health (SDOH) through strategic community partnerships. This paper explores how healthcare administrators can lead sustainable collaborations with public health agencies, nonprofits, and local organizations to reduce disparities, improve outcomes, and manage population health more effectively. Drawing from real-world examples in food insecurity, housing support, and preventive care, and framed by implementation challenges and policy implications, this paper offers a strategic roadmap for integrating community engagement into hospital operations.  

The findings highlight the tangible benefits of these partnerships, including reduced hospital readmissions, improved chronic disease outcomes, and enhanced trust in care delivery systems. This paper underscores the evolving role of hospital leadership in advancing health equity, expanding access to essential services, and aligning care delivery with long-term population health goals.  

Intro: A New Mandate for Hospitals

Hospitals have traditionally served as reactive hubs of acute care. Yet, in an era defined by rising chronic disease prevalence, health inequities, and escalating costs, this care model no longer suffices. Healthcare administrators are increasingly tasked with guiding hospitals beyond their conventional clinical roles to embrace proactive community health leadership.  

Recent studies, including those featured in the American Journal of Healthcare Strategy, highlight the critical role hospitals can play in addressing upstream social determinants of health (SDOH), such as housing, nutrition, employment, transportation, and access to preventive services. For example, the AHA’s 2018 compendium on hospital-community partnerships illustrates how local collaborations have measurably improved patient outcomes and reduced preventable hospital utilization. By forming strategic alliances with community stakeholders, hospitals can influence these variables, reduce disparities, and align more closely with value-based payment models.  

This paper explores strategic approaches for hospital administrators to lead sustainable partnerships with public health stakeholders, emphasizing models that address SDOH and drive health equity. It identifies common barriers to implementation and proposed forward-looking solutions grounded in sustainability, collaboration, innovation.  

Understanding Social Determinants of Health (SDOH) in Context  

The World Health Organization defines SDOH as the non-medical factors that influence health outcomes: the conditions in which people are born, grow, live, work and age. In the United States, these factors contribute significantly to disparities across racial, geographic, and socioeconomic groups. According to the Centers for Disease Control and Prevention (CDC), up to 50% of health outcomes are attributable to SDOH (CDC, 2023).  

Despite their impact, hospitals have historically been underutilized in addressing these determinants. Much of this stems from legacy fee-for-service models that prioritize volume over value. However, the shift toward value-based care has sparked a new paradigm in which addressing SDOH is no longer just a public health concern, it is a strategic priority.  

In line with this shift, the Centers for Medicare, and Medicaid Services (CMS) released 2023 guidance encouraging the use of Z-codes to document patients’ SDOH in electronic health records. These codes are becoming an integral part of value-based models and quality improvement programs, signaling that addressing social needs is now a core component of care delivery and reimbursement.  

Strategic Implications for Administrators  

For healthcare leaders, the shift to value-based care requires developing organizational competencies that extend beyond traditional clinical delivery. Hospital administrators must build internal support for non-clinical interventions, cultivate enduring cross-sector partnerships, and invest in long-term community health initiatives. While these efforts may not yield immediate financial returns, they are essential for organizational sustainability, health equity, and alignment with emerging reimbursement models.  

Case Studies: Hospitals Taking Action 

Addressing Food Insecurity through Clinical-Community Linkages  

Food insecurity affects more then 34 million people (about twice the population of New York) in the U.S., including 9 million children (about half the population of New York). For individuals managing chronic conditions like diabetes and hypertension, inconsistent access to nutritious food can directly undermine care plans and outcomes.  

Several hospitals have responded by developing “food prescription” programs in collaboration with local food banks and nutrition-focused nonprofits. The ProMedica health system in Ohio, for example, screens patients for food insecurity and issues produce vouchers redeemable at local markets. The program also integrates dietary education and counseling as part of its wraparound services.  

These programs are often funded through community benefit allocations, and in some states, qualify for Medicaid Section 1115 waivers under health innovation models. Early evaluations show improvements in clinical outcomes and reductions in emergency department visits among participants.  

Figure 1: Real-world outcomes from ProMedica’s SDOH interventions, showing the health and economic impact of connecting patients with services vs not 

Recent impact data from ProMedica’s Food Pharmacy program offers compelling evidence of the value of clinical-community linkages. Among patients identified as food insecure, those who were successfully connected to support services experienced a 53% reduction in hospital readmissions, a 4% decrease in emergency department use, and a 30% decrease in cost per member per month (PMPM). In contrast, those not connected to services saw PMPM costs rise by 30%, underscoring the financial and clinical risks of inaction. Additionally, high-risk pregnant patients who were referred and engaged in care coordination experienced a 90% rate of healthy birth outcomes, highlighting the broader potential of SDOH interventions in maternal health.  

Strategic Takeaway: 

Hospitals can use their electronic health records (EHR) and care coordination systems to find food-insecure patients and partner with community-based organizations to deliver tailored nutritional support. This model also aligns with Accountable Care Organizations (ACOs) and shared savings programs under value-based contracts.  

Housing Stability as a Healthcare Intervention 

A stable living environment is one of the strongest predictors of health. Yet, many hospitals continue to discharge patients into housing insecurity or homelessness, particularly in urban centers. This worsens chronic conditions and leads to elevated rates of readmission and emergency care use.  

Kaiser Permanente, for example, launched its Thriving Communities Fund, a $400 million initiative to increase affordable housing in its service regions through land acquisition, housing development, and community investment. Similarly, Boston Medical Center uses a medical-legal partnership, embedding housing attorneys directly into clinical care teams to help prevent evictions and resolve housing-related legal issues for at-risk patients.  

Other hospitals have partnered with Continuums of Care (CoCs), nonprofit developers, and local housing authorities to provide transitional, supportive, or permanent housing solutions for medically vulnerable individuals, including those recovering from inpatient stays or experiencing chronic homelessness.  

Figure 2: Kaiser Permanente’s 2023 investment in affordable housing and economic development, supporting the creation or preservation of 4,800 housing units 

Kaiser Permanente has taken a leadership role in addressing housing as a health imperative through its Thriving Communities Fund. In 2023 alone, the organization invested $273 million toward affordable housing and economic development across its service regions. These investments contributed to the creation or preservation of 4,800 affordable housing units, concentrated in Northern California. This strategy illustrated how health systems can go beyond traditional care delivery by addressing upstream determinants like housing security, which are intricately linked to long-term patient stability and reduced healthcare utilization.  

Strategic Takeaway: 

While housing programs require significant coordination and resources, they yield both clinical and financial benefits over time. Administrators should evaluate how housing instability contributes to readmissions, delayed follow-up care, or poor medication adherence within their populations, and consider embedding housing navigation services or community partnerships into discharge planning workflows.  

Preventive Care Outreach and Mobile Services 

Preventive services are vital in identifying health risks early and managing chronic disease, yet millions of Americans, particularly those in rural, low-income, or medically underserved areas, lack consistent access. To bridge this gap, hospitals have begun deploying mobile health units, hosting community health fairs, and partnering with local organizations to provide on-site screenings, immunizations, and preventive education.  

The University of Maryland Medical System, for example, operates a mobile health program that delivers care directly to low-income neighborhoods. These mobile units are often coordinated with faith-based organizations, schools, and community centers to build trust and improve outreach. Such collaborations help hospitals reach populations that may otherwise delay or forgo preventive care.  

In many cases, hospitals also employ community health workers (CHWs): trusted community members who serve as liaisons between patients and the health system. CHWs play a critical role in enhancing care continuity, addressing transportation barriers, navigating language differences, and reinforcing preventive guidance.  

Figure 3: University of Maryland Capital Region Health Mobile Program (2023) 

In 2023, March of Dimes, affiliated mobile health units provided over 4,390 patient visits, including 2,542 prenatal and 346 postpartum visits. Notably, 68% of visits served uninsured patients, and services were delivered on more than half of the days of the year (51%) across 23 mobile health locations. These programs have seen a 33% increase in total visits and a 48% increase in patients served since 2021, highlighting the growing demand and effectiveness of mobile care models in addressing maternal health and SDOH challenges in underserved communities.  

Strategic Takeaway: 

Outreach programs enable hospitals to proactively manage population health, improve access, and reduce reliance on emergency services. Administrators should explore scalable outreach models and evaluate performance using metrics such as emergency department diversion, reach into priority zip codes, health screening uptake, and community satisfaction rates.  

Table 1: Case Study Summary 

Summary of hospital-community partnership initiatives and their documented health and economic outcomes, based on real-world implementations. 

Strategies for Building and Sustaining Partnerships  

Mapping and Engaging Local Stakeholders  

Successful partnerships begin with a comprehensive understanding of the local health ecosystem. Hospitals can conduct stakeholder mapping to identify organizations aligned with their health equity and population improvement goals. These stakeholders may include public health departments, Federally Qualified Health Centers (FQHCs), behavioral health agencies, housing providers, schools, and faith-based institutions.  

Forming community advisory councils, hosting listening sessions or embedding community representatives into hospital planning and governance committees can help align goals, surface lived experiences and build long-term trust.  

Aligning Missions & Metrics  

Hospitals and community organizations often operate under different mandates, times, and metrics for success. Early in the collaboration, both parties should define shared objectives, develop clear data-sharing agreements, and identify outcomes that matter to both systems and communities. Tools such as logic models, mutually agreed key performance indicators (KPIs), and cross-sector dashboards are critical for keeping initiatives aligned and transparent.  

Securing Funding & Policy Support  

Partnerships require stable and diversified funding to succeed beyond initial grant cycles. In addition to internal hospital funds, administrators should pursue:  

• Federal and state grants (HRSA, CDC, CMS innovation models)  

• Medicaid managed care incentives tied to community-based interventions  

• Community Health Needs Assessment (CHNA)- lined investments  

• Philanthropic support, foundation grants, and corporate sponsorships  

Establishing a designated Office of Community Health or a full-time partnership integration can lead institutionalize efforts, ensure accountability, and foster stronger external engagement.  

Overcoming Challenges & Barriers 

Despite strong intent, many hospital-community partnerships falter due to the following:  

• Leadership Resistance: Change fatigue, limited bandwidth, or a focus on short-term revenue can lead to inertia. Senior executives must champion community health as a strategic pillar, not just a compliance requirement or public relations initiative, and communicate this commitment across the organization.  

• Funding Instability: Grant-based programs often suffer from uncertainty or short timelines. To scale and sustain efforts, hospitals must embed them into core operating budgets or value-based payment arrangements, ensuring long-term alignment with organizational priorities.  

• Staff Capacity and Burnout: Cross-sector work demands time, coordination, and relationship management, often from staff already stretched thin. Post-pandemic workforce shortages and fatigue have made it more difficult to sustain initiative without additional support. Leaders must account for this by investing in protected time, adequate staffing, and wellness safeguards for those leading community engagement.  

• Data Limitations: Many community partners lack the infrastructure for consistent data collection or exchange. Hospitals can support capacity-building, shared data systems, and privacy compliance training to bridge gaps and foster transparency.  

• Community Mistrust: Marginalized communities may have historical and ongoing reasons for distrusting healthcare institutions. Engaging communities with cultural humility involves more than outreach, it requires co-designing initiatives, hiring community-facing staff, and transparency in impact reporting. These efforts must be grounded in Diversity, Equity, and Inclusion (DEI) principles and reflect a commitment to shared power and representation.  

Strategic Response: To navigate these challenges, hospital leaders should invest in cross-functional trams, launch pilot programs to demonstrate return on investment (ROI) and publicly communicate their community investment strategy to both internal and external stakeholders. This transparency fosters trust and ensures accountability for sustained partnership success.  

Policy & Market Implications 

Healthcare’s shift to value-based care, from CMS’s ACO REACH model to Medicaid Section 1115 transformation waivers, is accelerating the expectation that hospitals address population-level needs through strategic, community-based interventions.  

Key policy levers that can support hospital-community collaboration include:  

• Flexible Medicaid waivers and state-led SDOH demonstration pilots that fund housing, nutrition, and transportation services  

• Incentives for cross-sector partnerships built into value-based payment models, including risk-sharing agreements with community-based organizations  

• Standardized SDOH screening protocols and documentation guidelines (Z-codes, ICD-10), enabling more accurate risk adjustment and reimbursement  

• Expanded Community Health Needs Assessment (CHNA) enforcement and regulatory accountability tied to community benefit investments 

Table 2: SDOH Policy Levers and Stakeholders: 

Key U.S. policy levers enabling hospital-community collaborations to address social determinants of health, with corresponding implementation stakeholders.  

Payers, including commercial insurers and Managed Care Organizations (MCOs), are beginning to recognize the return on investment (ROI) of addressing social needs. Value-based arrangements that integrate social interventions, such as housing navigation or food security programs, are increasingly seen as cost-saving strategies that also improve care quality and member satisfaction.  

Conclusion: Redefining the Hospital’s Role 

Hospitals are no longer just buildings that respond to illness; they are institutions with the potential to shape the conditions that promote health. This paper highlights how administrators can move from episodic, grant-driven interventions to sustained, strategic collaboration with community partners that is embedded into operational goals.  

Food prescription programs, housing stability initiatives, and preventive outreach models offer compelling evidence of how addressing social needs alongside clinical care improves outcomes and reduces long-term costs. To be successful, however, these efforts must be championed by hospital leadership, supported with durable funding, and rooted in authentic, trust-based relationships with the communities they aim to serve.  

In summary, hospitals can advance health equity by focusing on three core strategies: 

• Expanding access to nutritious food through clinical-community partnerships  

• Integrating housing navigation into care transitions to reduce readmissions  

• Deploying preventive services via mobile clinics and community health workers  

As healthcare systems continue to evolve toward value-based care, the mandate is clear: hospitals must think beyond their walls and lead the way in building healthier, more resilient communities.  

References: 

American Hospital Association. (2017). Hospital-community partnerships to build a culture of health: A compendium of case studies.  

American Journal of Healthcare Strategy. (2025). Looking toward 2025: How payers will evolve.  

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Boston Medical Center. (2022). Housing advocacy and medical-legal partnerships.  

Centers for Disease Control and Prevention. (2023). Social determinants of health.  

Gundersen, C., & Ziliak, J. P. (2015). Food insecurity and health outcomes. Health Affairs, 34(11), 1830–1839.  

Kaiser Permanente. (2023). Improving health, investing in social good.  

March of Dimes. (2023). Mobile health impact report.  

National Academy of Medicine. (n.d.). Advancing health care.  

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Shi, L., & Singh, D. A. (2022). Delivering health care in America: A systems approach (8th ed.). Jones & Bartlett Learning. 

University of Maryland Medical System. (2021). Mobile health program.  

World Health Organization. (n.d.). Social determinants of health.